Blood pressure recording bias during a period when the Quality and Outcomes Framework was introduced

Carey, Iain M.; Nightingale, Claire M; DeWilde, Stephen; Harris, Tess; Whincup, Peter H.; Cook, Derek G

doi:10.1038/jhh.2009.18

Cited by 25 publications

(21 citation statements)

References 17 publications

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“…The percentage meeting targets are usually derived from one blood pressure measurement which could overestimate or underestimate the number of HCP due to the variability of blood pressure levels. 29 However, our findings show that the percentage of patients classified a HCP are consistent with other studies analysing QOF data. 19–30 …”

Section: Discussionsupporting

confidence: 92%

Differences in the classification of hypertensive controlled patient in primary care: Cross sectional study

et al. 2012

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ObjectivesTo examine differences in blood pressure control using the 2006 National Institute for Health and Clinical Excellence (NICE) guidelines and the 2007 Quality and Outcome Framework (QOF) standards.DesignCross-sectional study.Setting28 general practices located in Wandsworth, London.ParticipantsHypertensive patients aged 17 years and over.Main outcomes measuresPercentage of hypertensive patients classified as a hypertensive controlled patient (HCP) by each standard.Results79.5% of patients were classified as a HCP by the QOF target and 60.7% by the NICE target. 93% and 14% of practices had more than 70% of patients classified as a HPC by using the QOF and NICE targets respectively. By applying the QOF target, men aged 45–64 years and 65 years and over had significantly higher probability of being classified as a HCP compared to those aged 17–44 years, OR 1.34 (1.08–.165) and OR 2.15 (1.61–2.87) respectively. Regardless of the target, for men the probability of being classified as a HCP increased with age.ConclusionBetter achievement of blood pressure control targets is present when the less stringent QOF target is used. Men aged 65 years and over were more likely to be classified as a HCP. Greater consistency is needed between the clinical targets in QOF and NICE guidance.

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Section: Discussionsupporting

confidence: 92%

Differences in the classification of hypertensive controlled patient in primary care: Cross sectional study

et al. 2012

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“…Third, measurements of biological variables are subject to error, particularly in the case of BP, which is measured using instruments of variable accuracy and is prone to digit bias in recording [23]. Also, since 2004, UK practices have had financial incentives for controlling BP and there is evidence to show that recordings of systolic BP have been biased downwards for patients with values just above the target levels (target levels for diabetic patients were 145 mmHg from 2004/2005 to 2010/2011 and 140 mmHg from 2011/2012) [24]. Fourth, some risk factor measurements might be missing not at random (MNAR), as our analyses assume, although multiple imputation offers some protection against biased estimates [25,26].…”

Section: Discussionmentioning

confidence: 99%

Glucose, blood pressure and cholesterol levels and their relationships to clinical outcomes in type 2 diabetes: a retrospective cohort study

et al. 2014

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Aims/hypothesis We aimed to describe the shape of observed relationships between risk factor levels and clinically important outcomes in type 2 diabetes after adjusting for multiple confounders.Methods We used retrospective longitudinal data on 246,544 adults with type 2 diabetes from 600 practices in the Clinical Practice Research Datalink, 2006Datalink, -2012 Proportional hazards regression models quantified the risks of mortality and microvascular or macrovascular events associated with four modifiable biological variables (HbA 1c , systolic BP, diastolic BP and total cholesterol), while controlling for important patient and practice covariates. Results U-shaped relationships were observed between allcause mortality and levels of the four biometric risk factors. Lowest risks were associated with HbA 1c 7.25-7.75% (56-61 mmol/mol), total cholesterol 3.5-4.5 mmol/l, systolic BP 135-145 mmHg and diastolic BP 82.5-87.5 mmHg. Coronary and stroke mortality related to the four risk factors in a positive, curvilinear way, with the exception of systolic BP, which related to deaths in a U-shape. Macrovascular events showed a positive and curvilinear relationship with HbA 1c but a U-shaped relationship with total cholesterol and systolic BP. Microvascular events related to the four risk factors in a curvilinear way: positive for HbA 1c and systolic BP but negative for cholesterol and diastolic BP. Conclusions/interpretation We identified several relationships that support a call for major changes to clinical practice. Most importantly, our results support trial data indicating that normalisation of glucose and BP can lead to poorer outcomes. This makes a strong case for target ranges for these risk factors rather than target levels.Electronic supplementary material The online version of this article

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“…Carey et al (2009) discover a reporting bias in clinical indicators, noting that patients in the U.K. QOF are significantly more likely to narrowly meet than narrowly miss a P4P performance target. Shen et al (2003) observe that performance-based contracting leads to patient selection.…”

Section: Literature Reviewmentioning

confidence: 99%

“…Clinical measures could be misreported in borderline cases in order to meet performance targets (Carey et al 2009). Furthermore, patient selection may occur: providers could select patients based on their probability to meet P4P quality measures (e.g., Shen 2003, Rosenthal & Frank 2006Casalino & Elster 2007), a practice that could result in diminished access to care (Epstein et al 2004) and growing health disparities for already disadvantaged patients (Hong et al 2010).…”

Section: Introductionmentioning

confidence: 99%

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Blood pressure recording bias during a period when the Quality and Outcomes Framework was introduced

Cited by 25 publications

References 17 publications

Differences in the classification of hypertensive controlled patient in primary care: Cross sectional study

Differences in the classification of hypertensive controlled patient in primary care: Cross sectional study

Glucose, blood pressure and cholesterol levels and their relationships to clinical outcomes in type 2 diabetes: a retrospective cohort study

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